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Unusual computed tomography findings in a patient presenting with acute abdominal pain

BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b3192 (Published 19 August 2009) Cite this as: BMJ 2009;339:b3192

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Typical radiological features of pneumatosis intestinalis

JKK Chan and colleagues’ recent pictorial quiz showed CT imaging
depicting portal venous gas and pneumatosis intestinalis, as a result of
acute mesenteric ischaemia.1 Whilst we appreciate that the CT
examination demonstrated bowel wall gas in this patient, the selected
axial image does not depict the typical imaging features of intramural
gas. Gas may collect peripherally within the lumen of the bowel, around
faecal material and can simulate pneumatosis – a recognised radiological
pit-fall. We present typical radiological features of pneumatosis
intestinalis, showing mural gas in a circumferential distribution, and
importantly, within the dependent portion of the bowel as to confirm its
mural, rather than, luminal location. (Fig1)

Fig1: Unenhanced coronal (A) and axial (B&C) images showing pneumatosis intestinalis (arrowheads), portal vein gas (arrows) and gas within the superior mesenteric vein - splenic vein confluence (dashed arrow).

Pneumatosis intestinalis with or without portomesenteric gas has a
wide differential diagnosis (Emphysema, infective enteritis, connective
tissue disorders, ischaemia, leaukaemia, organ transplantation, steroid
and chemotherapy use, to name a few), and is not an uncommon finding in
non-ischaemic conditions.2 The stated high specificity for pneumatosis
and portal vein gas in acute bowel ischaemia is based on retrospective
studies in pre-selected groups of patients.3 This highlights the
importance of correlation with clinical, laboratory and radiological
findings to achieve a universal diagnosis.

References:

1. Chan JKK, Lovegrove R, Dunckley M, Woo EK, Farouk M. Unusual computed
tomography findings in a patient presenting with acute abdominal pain.
BMJ 2009;339:b3192

2. Ho L, Paulson EK, Thompson WM. Pneumatosis Intestinalis in the
Adult: Benign to Life-Threatening Causes. AJR 2007;188:1604-13

3. Wiesner W, Khurana B, Ji H, Ros P. CT of acute bowel ischemia.
Radiology 2003;226:635-50.

Competing interests:
None declared

Competing interests: No competing interests

28 September 2009
Chirag M Patel
SpR Clinical Radiology
Nicos Fotiadis (Consultant Interventional Radiologist)
Barts & The London NHS Trust, The Royal London Hospital, Whitechapel, London, E1 1BB.
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